Chronic Care Management Coordinator (LPN)

Teche Action Clinic • Franklin, LA

109d

About The Position

The Chronic Care Management Coordinator (CCM Coordinator) provides care management for adult and pediatric patients with complex illness, in the primary care setting, under the supervision of the Chronic Disease Project Manager. In partnership with the primary care practice leadership team, the CCM Coordinator leads care management within the team through process improvement, workflow redesign, helping with training, and delegating to other members of the team. Serves in an expanded health care role to collaborate with specialists, members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services. Assesses plans, implements, coordinates, monitors, and evaluates all options and services with the goal of optimizing the patient's health status. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care. Provides other duties as assigned by Chronic Disease Project Manager. Provides targeted interventions to avoid hospitalization and emergency room visits. Coordinates care across settings and helps patient/families understand health care options.

Requirements

• License Practical Nurse, or Master of Social Work License preferred.
• Two years of experience with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting.
• Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education.
• Critical thinking skills and ability to analyze complex data sets.
• Ability to manage complex clinical issues utilizing assessment skills and protocols.
• Excellent assessment and triage skills.
• Demonstrates excellent communication - both verbal and written.
• Excellent interpersonal and facilitation skills.
• Ability to affect change, work as a productive and effective team member, and adapt to changing needs/priorities.
• General computer knowledge and capability to use computer.

Nice To Haves

• Associate's degree or higher, in clinical field (preferred).
• Care management experience (preferred).
• Experience as participant in continuous quality improvement (preferred).
• Completion of self-management support training (preferred).

Responsibilities

• Identifies the targeted CCM population within practice site(s) per PCP referral, risk stratification, and patient lists.
• Assesses over time the health care, educational, and psychosocial needs of the patient/family.
• Collaborates with PCP, patient, and members of the health care team to develop a comprehensive individualized plan of care.
• Provides patient self-management support with a focus on empowering the patient/family.
• Implements a system of care that facilitates close monitoring of high-risk patients.
• Coordinates patient care through ongoing collaboration with PCP, patient/family, community, and other members of the health care team.
• Provides follow-up with patient/family when patient transitions from one setting to another.
• Demonstrates excellent written, verbal, and listening communication skills.
• Maintains required documentation for all care management activities.
• Works with practice and PO/PHO leadership to continuously evaluate process and propose/develop process improvement strategies.
• Reviews current literature regarding effective engagement and communication strategies.
• Participates/Reports in Quality Assurance Performance Improvement (QAPI) Committee.
• Oversees the patient evaluation data and makes recommendations to team members.

Benefits

• Medical, Vision and Dental Health Insurance
• Accidental Insurance
• Critical Illness Insurance
• Long Term Benefits
• Short Term Benefits
• Free Life Insurance
• 401K Plan Benefits
• Paid Vacation
• Paid Sick Time
• Set Schedule
• No Weekends
• National Health Service Corps Site
• 11 paid holidays
• Family-Friendly Work Environment
• Eligible for Student Loan Forgiveness through Federal and State Programs

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree
• Number of Employees: 251-500 employees